Appeals Administrator
1199SEIU Family of Funds - New York, NY

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Responsibilities

Maintain and enhance strategic plans to improve the Plan’s current appeals processes throughout all relevant departments to assure compliance with ERISA, PPACA and the DOL regulations.

Resolve issues regarding workflow and other matters; maintain control of workflow while encouraging suggestions for improvement; establish a proactive approach to problem solving.

Build and lead a multi-departmental team that researches, reviews and resolves member appeals and interprets and explains health plan benefits, policies and procedures to members and providers.

Manage and supervise daily operations of support staff who administer ongoing tracking, trending and reporting for assigned appeals.

Coordinate and follow-up with appropriate departments including legal counsel, Trustees and other professionals until resolution; producing or reviewing complex written correspondence.

Other duties and projects as assigned

Qualifications

Minimum of a Bachelor’s degree in a related field, advanced degree (such as RN) in related field a plus, or the equivalent years work experience required; plus

Minimum six (6) years relevant work experience in high-level project coordination preferably in a healthcare or insurance setting required, to include four (4) years practical experience supervising and/or working with both exempt and non-exempt personnel regarding performance, coaching and counseling matters.

Demonstrated process management and development experience required; strong analytical thinking required.

Knowledge of quality assurance and performance improvement processes.

Strong fundamental understanding of the requirements of ERISA and DOL as they relate to appeals.

Experience conducting clinical case reviews; utilization management and risk management helpful

Effective verbal and written communication and interpersonal skills along with excellent customer service skills.

Demonstrated management skills; knowledge of medical claims or prior clinical experience a plus.

Must be professional, detail oriented, clear and concise, with ability to work independently and to develop a multi-discipline team.

Experienced with PC based software including Microsoft Word, Excel and Access.

Must meet performance standards including attendance and punctuality.

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